Maximizing Reimbursements While Maintaining Compliance
As healthcare continues to evolve, Medicare Advantage (MA) plans face increasing scrutiny over the accuracy of diagnoses and payments. A recent investigative report by the Wall Street Journal highlights that MA insurers were paid a staggering $50 billion from 2018 to 2021 for questionable diagnoses. Many of these diagnoses, such as diabetic cataracts, were added to patients' medical records without any subsequent care or treatment, raising concerns about potential upcoding and fraud.
The study exposed flaws in the system, revealing that thousands of patients were diagnosed with conditions they likely did not have. For instance, UnitedHealth members were 15 times more likely to be diagnosed with diabetic cataracts than patients in traditional Medicare, even though these patients had already undergone cataract surgery, making a recurrence of the condition impossible.
These findings have led to increased oversight, with the Office of Inspector General discovering that nearly 69 percent of diagnoses used for risk adjustment had no support, resulting in over $100 million in overpayments. However, changes are underway. CMS has implemented reforms, such as a new v28 risk adjustment model introduced in 2024 to better align payments with accurate diagnoses.
ForeSee Medical Can Help
You deserve proper compensation, and with the evolving dynamics in healthcare, there's a critical need for precise and efficient risk adjustment processes. ForeSee Medical's AI-driven risk adjustment software provides a robust, compliant tool for HCC coding, ensuring healthcare providers and insurers are fairly compensated within the complex Medicare Advantage environment.
A Few of ForeSee’s Advanced Features
Real-Time Coding Accuracy
ForeSee Medical’s software ensures that coding is accurate and compliant by analyzing patient data in real-time. The AI engine scans clinical notes, lab results, and diagnostic tests to automatically suggest appropriate HCC codes based on documented conditions. This reduces the likelihood of errors caused by manual coding and ensures that all relevant diagnoses are captured without upcoding or adding unsupported conditions.
Compliance with CMS Reforms
With CMS introducing new risk adjustment models and audits, compliance is more important than ever. ForeSee Medical’s software is regularly updated to reflect the latest regulatory changes, ensuring that providers and plans meet all CMS requirements. This proactive approach minimizes the risk of audits, penalties, and clawbacks for overpayments, which have plagued the industry in recent years.
Enhanced Audit Readiness
As scrutiny intensifies, being prepared for audits is critical. ForeSee Medical’s AI-driven platform keeps a thorough record of each patient’s medical history, diagnoses, and treatments, ensuring that every HCC code is backed by supporting documentation. This transparency allows providers to demonstrate compliance with risk adjustment regulations during audits, reducing the risk of penalties and fines.
Maximizing Legitimate Compensation
By ensuring that HCC coding is accurate and thorough, ForeSee Medical helps providers and MA plans maximize legitimate compensation for the care they deliver. This is especially important in an era where CMS is clamping down on overpayments, particularly for conditions like diabetic cataracts, which will no longer receive higher payments under the new risk adjustment model.
Improved Patient Outcomes
Accurate HCC coding not only ensures proper compensation but also improves patient care. By capturing a complete and accurate picture of a patient’s health, providers can ensure they receive the appropriate treatments and interventions, reducing the risk of complications and hospitalizations. ForeSee Medical’s platform supports this by offering insights into care gaps and risk factors, allowing providers to take a proactive approach to patient care.
Looking Forward
The Wall Street Journal report underscores the challenges MA plans face with risk adjustment, and the scrutiny around improper diagnoses will only increase. However, with AI-powered solutions like ForeSee Medical’s software, healthcare organizations can ensure they are properly compensated for the care they deliver while maintaining compliance with ever-evolving CMS regulations.
As lawmakers and federal watchdogs continue to monitor the integrity of risk adjustment payments, having a reliable, AI-powered platform in place will be critical for success in the Medicare Advantage space. By leveraging ForeSee Medical’s innovative technology, healthcare providers and insurers can improve both patient care and financial outcomes, while safeguarding themselves against the risks of upcoding and non-compliance.
In a complex, high-stakes environment like Medicare Advantage, it’s essential to have the right tools in place. ForeSee Medical’s AI-powered software provides the accuracy, compliance, and efficiency needed to navigate the challenges of risk adjustment and HCC coding, ensuring that healthcare organizations receive the compensation they deserve—ethically and transparently.
Blog by: The ForeSee Medical Team